Professional Communication in Nursing NRS 101

Communication
Human interaction
Verbal and nonverbal Written and unwritten Planned and unplanned

Conveys thoughts and ideas Transmits feelings Exchanges information Means various things

Communication, continued
Effective communication Intrapersonal level self-talk Clear communication essential
Client safety Collaboration with diverse team challenged by
Current health care environment Professional communication and collaboration Cultural gaps Available resources and technology

The Communication Process

Sender
Source-encoder

Message
What is actually said/written, body language How words are transmitted channel

Receiver
Listener decoder perception of intention

Response Feedback

Verbal Communication
Pace and intonation Simplicity Clarity and brevity
Congruence

Timing and relevance Adaptability Credibility Humor

Nonverbal Communication
Body language
Gestures, movements, use of touch

Essential skills: observation, interpretation

Personal appearance Posture and gait Facial expression of self, others; eye contact

Gestures
Cultural component

Electronic Communication
Advantages
Fast Efficient Legible Improves communication, continuity of care

Disadvantages
Client confidentiality risk HIPPA Socioeconomics

Electronic Communication,
continued Do not use e-mail
Urgent information
Jeopardy to clients health

Highly confidential information Abnormal lab data

Other guidelines
Agency-specific standards and guidelines Part of medical record Consent, identify as confidential

Effective Written Communication

Does not convey nonverbal cues Same as verbal AND Appropriate language and terminology Correct grammar, spelling, punctuation Logical organization Appropriate use and citation of resources

Factors Influence Communication Process

Development & gender Sociocultural characteristics Values and perception Personal space and territoriality Roles and relationships Environment Congruence Attitudes

Development
Language and communication skills develop through stages Communication techniques for children
Play Draw, paint, sculpt Storytelling, word games Read books; watch movies, videos Write

Gender
Females and males communicate differently from early age Boys establish independence, negotiate status Girls seek confirmation, intimacy

Sociocultural Characteristics
Culture Education Economic level

Values and Perception

Values standards that influence behavior Perceptions personal view of an event Unique personality traits, values, experiences Validate

Personal Space
Defined as distance people prefer in interactions with others Proxemics
Intimate distance frequently used by nurses Personal distance less overwhelming Social distance increased eye contact
Out of reach for touch

Public distance

Figure 36-5 Personal space influences communication in social and professional interactions. Encroachment into another individuals personal space creates tension.

Territoriality
Space and things
Individual considers as belonging to self Knock before entering space

May be visible
Curtains around bed unit Walls of private room Removing chair to use at another bed

Roles and Relationships

Between sender and receiver First meeting versus developed relationship Informal with colleagues Formal with administrators Length of relationship

Environment
Can facilitate effective communication Key factors
Comfort Privacy

Congruence
Congruence
Verbal and nonverbal aspects match Seen by nurse and clients

Incongruence
Senders true meaning in body language

Improving nonverbal communication

Relax; use gestures judiciously Practice; get feedback on nonverbal

Attitudes
Interpersonal attitudes
Attitudes convey beliefs, thoughts, feelings Caring, warmth, respect, acceptance
Facilitate communication

Condescension, lack of interest, coldness

Inhibit communication

Effective nursing communication

Significantly related to client satisfaction

Respect

Barriers to Communication
Stereotyping Agreeing and disagreeing Being defensive Challenging Probing Testing

Rejecting Changing topics Unwarranted reassurance Passing judgment Giving common advice

Therapeutic Communication
Interactive process between nurse, client Helps client overcome temporary stress
To get along with other people Adjust to the unalterable Overcome psychological blocks

Established with purpose of helping client Nurse responds to content

Verbal, nonverbal

Therapeutic Communication Techniques

Empathizing
Empathy is process
People feel with one another Embrace attitude of person who is speaking Grasp idea that what client has to say important

NOT synonymous with sympathy Interprets clients feelings without inserting own

Empathy
Empathy
Four phases of therapeutic empathizing
Identification Incorporation Reverberation Detachment

On guard against over-distancing or burnout

Listening
Attentive listening
Mindful listening Paying attention to verbal, nonverbal Noting congruence Absorbing content and feeling Listening for key themes Be aware of own biases Highly developed skill

Blocks to Attentive Listening

Rehearsing Being concerned with oneself Assuming Judging Identifying Getting off track Filtering

Attending
Physical attending
Face the person squarely Adopt an open posture Lean toward the person Maintain good eye contact Try to be relatively relaxed

Silence
Using silence
Encouraging the client to communicate Allowing client time to ponder what has been said Allow client time to collect thoughts Allow client time to consider alternatives Look interested Uncomfortable silence should be broken
Analyzed

Reflection
Reflecting
Repeating the clients message
Verbal or nonverbal

Reflecting content repeats clients statement

May be misused, overused Use judiciously

Reflecting feelings
Verbalizing implied feelings in clients comment

Encourages client to clarify

Just the Facts

Imparting information
Supplying additional data Not constructive to withhold useful information Line between information and advice Avoid personal, social information Client participation in decision making positive mental health outcomes
Take in and understand information Educated empowered client

Deflection
Avoiding self-disclosure
Deflect a request for self-disclosure
Honesty Benign curiosity Refocusing Interpretation Clarification Feedback and limit setting

Assess and evaluate responses

Clarification
Clarifying
Attempt to understand clients statement Ask client to give an example

Paraphrasing
Nurse assimilates or restates in own words Fives nurse opportunity to test understanding

Checking perceptions
Sharing how one person perceives another

Question and Define

Questioning
Very direct way of speaking with clients Open-ended questions focuses the topic Close question limits choice of responses Careful not to ask questions that steer answer

Structuring
Attempt to create order, establish guidelines Define parameters of nurse-client relationship

Pinpoint and Link

Pinpointing
Calls attention to certain kinds of statements
Relationships

Point to inconsistencies Similarities, differences

Linking
Nurse responds to client
Ties together two events, experiences, feelings Connect past experiences with current behaviors

Giving Feedback
Nurse share reaction to what client said Give in a way that does not threaten client Risk of client experiencing feedback
Personal rejection

Nurses should be open, receptive to cues

Focus Feedback
On behavior, observations, description On more-or-less, rather than either/or On here-and-now: what is said, not why Sharing of information, ideas Exploration of alternatives Value to client Amount of information client able to use Appropriate time and place

Confronting
Deliberate invitation to examine some aspect of personal behavior that indicates discrepancy between actions and words Informational confrontation
Describes visible behavior

Interpretive confrontation
Draws inferences about the meaning of behavior

Six Skills in Confronting

Use of personal statements Use of relationship statements Use of behavior descriptions Use of description of personal feelings Use of responses aimed at understanding Use of constructive feedback skills

Summarize and Process

Summarizing
Highlighting the main ideas expressed Conveys understanding Reviews main themes of conversation Use at different times during interaction Dont rush to summarize

Processing
Direct attention to interpersonal dynamics

Therapeutic Communication Mistakes

Common mistakes
Giving advice Minimizing or discounting feelings Deflecting Interrogating Sparring

Barriers to Communication
Failure to listen Improperly decoding intended message Placing the nurses needs above clients

The Therapeutic Relationship

Growth-facilitating process
Help client manage problems in living
More effectively Develop unused, underused opportunities fully

Help client become better at helping self

May develop over weeks or within minutes Influenced by nurse and client
Personal and professional characteristics

Relationship Characteristics
Characteristics of therapeutic relationship
Intellectual and emotional bond
Focused on client

Respects client as individual Respects client confidentiality Focuses on clients well-being Based on mutual trust, respect, acceptance

Therapeutic Relationship Phases

Preinteraction Introductory Working: stage 1 and stage 2 Termination

Introductory Phase
Preinteraction phase Introductory phase
Orientation, pretherapeutic phase Nurse and client observe each other Open relationship Clarify problem Structure and formulate contract Client may display resistive behaviors

Introductory Phase, continued

By end of this phase client begins to
Develop trust in nurse View nurse as honest, open, concerned Believe nurse will try to understand, respect Believe nurse will respect client confidentiality Feel comfortable talking about feelings Understand purpose of relationship, roles Feel an active participant in plan

Working Phase Stages

Stage One
Exploring and understanding thoughts and feelings Empathetic listening and responding Respect, genuineness Concreteness Reflecting, paraphrasing, clarifying, confronting Intensity of interaction increases

Working Phase Stages, continued

Stage two
Facilitate and take action Collaborate Make decisions Provide support Offer options

Termination Phase
Difficult, ambivalent Summarizing Termination discussions Allow time for client adjustment to independence

Developing the Therapeutic Relationship

Set mutual goals with client Discuss outcomes Many ways of helping do not require training

Skills for the Therapeutic Relationship

Listen actively Help identify the clients feelings Be empathetic, honest, genuine, and credible Use ingenuity Be aware of cultural differences Maintain confidentiality Know your role and your limitations

Communication Techniques Working with Children and Families

Accepting Broad openings Clarifying Focusing Observations Reflection Summarizing Active listening Collaborating Exploring Giving recognition Offering self Restatement or paraphrasing Validating perceptions

Developmental Considerations
Establish rapport with children Sit or lower self to childs eye level Note what child is playing with or reading If appropriate, agree with child/share feelings Compliment a physical features, activity Use calm tone of voice, appropriate language Pace discussion, procedure in nonhurried manner Preschoolers have limited concept of time

Establish Trust
Establishing rapport
Include adolescent in discussion Listen more than you talk Avoid distractions Be truthful with the child

Establishing trust
Follow through with promises Respect confidentiality Be truthful, even if it isnt what they want

Conclusion
Nurses role requires communication skills Effective communication large role
Ability to deliver highest quality of care

Nurse needs to be understood Nurse needs to understand messages Strong verbal, written communication skills Monitor own nonverbal communication

Documentation
Effective communication vital to care Discussion Report Record Recording Charting Documenting Legal document

Ethical and Legal Considerations

American Nurses Association code of ethics Access to clients record restricted HIPAA regulations Students bound by strict ethical code Ensure confidentiality of computer records Personal password Never leave terminal unattended logged on Know policies of facility

Purposes of Client Records Communication Planning care Auditing health agencies Research Education Reimbursement Legal documentation Health care analysis

Documentation Systems
Source-oriented record Problem-oriented medical record Problems, interventions, evaluation (PIE) Focus charting Charting by exception Computerized documentation Case management

Source-Oriented Record
Notations for each discipline in separate sections of chart Narrative charting Being replaced or augmented Organize information in clear, coherent manner Convenient Scattered

Figure 36-8

An example of narrative notes.

Components of SourceOriented Record

Admission sheet Graphic record MAR Nurses notes Progress notes Diagnostic reports Physicians order sheet Referral summary Initial nursing assessment Daily care record Special flow sheet Medical H&P Consultation records Discharge plan

Problem-Oriented Record
Problem-oriented medical record (POMR) Arranged according to client problems Advantages Encourages collaboration Problem list alerts caregivers to clients needs Disadvantages Caregivers differ in ability to use format Vigilance to maintain up-to-date problem list Inefficient

POMR Components
Database Problem list Derived from database Listed in order identified Updated Plan of care Progress notes Same sheet for all notes

POMR Progress Notes

SOAP format frequently used Subjective Objective Assessment Plan SOAPIER Interventions Evaluation Revision

PIE System
Groups information Problems Interventions Evaluation of nursing care Flow sheets, incorporates ongoing care plan Assessment establishes, records problem NANDA Dx or develop problem statement

Focus Charting
Three columns usually used Date and time Focus: condition, nursing diagnosis, behavior, sign/symptom Progress note Data Action Response Holistic perspective

Figure 36-11 Example of the focus charting system.

Charting by Exception
Charting by exception (CBE) Flow sheets Standards of nursing care Bedside access to chart forms Advantages Elimination of lengthy, repetitive notes Presumption that nurse did assess client

Computerized Documentation
Manage huge volume of information Information easily retrieved, format variety Can generate work list for shift Relatively easy Standardized lists, add narrative information Speech recognition technology Transmit information between settings MDS

Computerized Documentation Pros

Facilitates focus on client outcome Fast, efficient use of time Legible Link various sources, links to monitors Bedside terminals Synthesize information Eliminate need for notes Permit immediate order checking

Computerized Documentation Cons

Client privacy concerns Breakdowns make information unavailable System expensive Extended training periods

Case Management
Emphasizes quality, cost-effective care Multidisciplinary approach Planning and documenting client care Critical pathway Incorporated graphics and flow sheets Goal not met is variance Unexpected outcome Document unexpected event

Figure 36-16 Excerpt from a critical pathway documentation form.

Figure 36-17

Example of Critical Pathway.

Case Management, continued

Advantages Promotes collaboration Helps to decrease length of stay Efficient use of time Goal-focused Disadvantages Best for clients with one or two diagnoses

Documenting Nursing Activities

Admission nursing assessment Nursing care plans Kardexes Flow sheet Progress notes Nursing discharge/referral summaries

Admission Nursing Assessment

Can be organized by health patterns Body systems Functional abilities Health problems and risks Nursing model Type of health care setting

Nursing Care Plans

JC requires clinical record include
Evidence of client assessments Nursing diagnoses and/or client needs Nursing interventions Client outcomes Evidence of a current nursing care plan

Traditional care plan written for each client Standardized care plans save time

Kardexes
Concise method for organizing, recording May/may not be part of permanent record May be in pencil May be organized into sections
Pertinent information, allergies Medications, IV fluids List of treatments, procedures Procedures orders

Kardexes, continued
Specific data on how physical needs to be met
Diet, assistance needed with feeding Elimination devices Activity Hygienic needs, safety precautions

Problem list with stated goals, nursing approaches Quick visual guide

Flow Sheet & Progress Notes

Flow sheet
Record data quickly, concisely Graphic record Input and output (I & O) Medication administration record (MAR) Skin assessment record

Progress notes
Progress, interventions, re/assessment data

Nursing Discharge
Completion on discharge/transfer
If given to client, family understandable terms

Transferred within facility, to/from long-term care facility

Report goes with client for continuity of care

Usually includes:
Clients status description, resolved problems

Referral Summaries
Usually include:
Unresolved continuing health problems Treatments to be continued Current medications Restrictions related to activity, diet, bathing Activities of daily living (ADL) abilities Comfort level Support networks

Referral Summaries, continued

Client education provided in relation to
Disease process Activities and exercise, special diet Medications Specialized care or treatment Follow-up appointments

Discharge destination and mode Referrals

Facility Specific Documentation

Long-term care documentation Home care documentation

Long-Term Care Documentation

Two types of care
Skilled or intermediate

Requirements based on
Professional standards Federal, state regulations
HCFA OBRA law Medicare and Medicaid requirements

Long-Term Care Documentation, continued

Nurse completes nursing care summary
Once a week for skilled-care clients Every 2 weeks for intermediate care Summary addresses:
Specific problems noted in care plan Mental status ADLs, hydration, nutrition status Safety measures needed Medications, treatments Behavior modification assessments

Long-Term Care Documentation, continued

MDS and plan of care within time specified Keep record of visits, family phone calls Requirements Review, revise care plan every 3 months
When clients health status changes

Document and report any systems change

Primary care provider, clients family Document interventions, progress

Home Care Documentation

Health Care Financing Administration (HCFA) mandated
Standardized Medicare and Medicaid

Two records required

Home health certification/plan of treatment form Medical update and client information form

Nurse completes forms

Home Care Forms

Comprehensive nursing assessment Plan of care Progress note at each visit
Note changes Interventions Client responses Vital signs as indicated

Monthly progress nursing summary

Home Care Forms, continued

Copy of care plan in clients home Report changes of plan of care to MD
Document that changes were reported

Encourage client, caregiver to record data Write discharge summary for physician
Notify reimbursers services discontinued

General Guidelines for Recording

Date and time Timing
NO recording prior to providing care

Legibility Permanence Accepted terminology

Approved by agency Joint Commission DO NOT USE LIST

General Guidelines for Recording, continued

Correct spelling Signature
Follow agency policy

Accuracy
Clients name, identifying information Observations and facts Recording a mistake
Draw line through it and write mistaken entry Name or initials

Figure 36-19 Correcting a charting error.

General Guidelines for Recording, continued

Sequence Appropriateness Completeness
Reflect nursing process Omitted care must also be recorded
What, why, who

Conciseness

Legal Prudence
Legal protection to nurse, caregivers, facility
And client

Admissible in court as legal document Adhere to professional standards Follow agency policy and procedures

Dos and Donts

Do
Chart changes Show follow-up Read prior notes Be timely Objective, factual Correct errors Chart teaching Quotes Responses

Dont
Leave blank spaces Chart in advance Use vague terms Chart for others Use patient or client Alter record Record assumptions